1. SPIRIT F OOD P ACKAGES

2. This module, SPIRIT Food Packages, is part of the WIC SPIRIT Readiness training series. The series is designed to be an overview of major changes in the Arkansas WIC Program and to prepare WIC staff for further training in regards to SPIRIT, the new Management Information System. The series includes VENA, the Value Enhanced Nutrition Assessment initiative; the WIC food packages, and nutrition risk factors. Let’s get started! You can track your progress with this handy guide.

3. O BJECTIVES Upon completion of this module, the CPA should be able to: 1. Identify the names of the new food packages 2. List the major changes to each food package 3. Define food package tailoring 4. Apply the basic concepts of tailoring in the WIC management information system SPIRIT

4. F OOD P ACKAGES Supplemental foods received will remain the same: Milk Cheese Juice Cereal Eggs Beans Peanut Butter (special issue; children > 2 or women) Tuna (exclusively BF only) Carrots (exclusively BF only)

5. T OTAL OF 11 FOOD PACKAGES WILL BE AVAILABLE THROUGH SPIRIT: Infant 1 Infant 2 Infant 3 Infant 4 Child 1 Child 2 Child 3 Child/Woman with Special Needs Pregnant/Partially BF Woman Exclusively BF Woman Non-breastfeeding Postpartum Woman

6. D EFAULT F OOD P ACKAGES These 11 food packages will be termed Default Food Packages in SPIRIT. These default food packages are what we used to term as standard food packages.

7. F OOD P ACKAGE VS F OOD P RESCRIPTION Food Packages: the basic food packages authorized by WIC Program Regulations for providing supplemental foods according to participant category. Food Prescription: the specific combination and quantities of allowable foods issued to WIC participants to address their nutritional, cultural and dietary related health needs.

8. I NFANT 1 (0 - 1 MONTH ) Infant formula

9. I NFANT 2 (2 - 3 MONTHS ) Infant formula

10. I NFANT 3 (4 - 5 MONTHS ) Infant formula

11. I NFANT 4 (6 – 11 MONTHS ) Infant formula 24 ounces infant cereal 2 containers juice

12. M AJOR C HANGES TO I NFANT P ACKAGES Infant packages were not divided by age Infants received infant cereal at 4 months of age Infants were issued 8 ounces infant cereal with the option of adding 16 ounces for a total of 24 ounces Infant food packages divided by age Infants will receive infant cereal at 6 months of age Infants will be issued 24 ounces of infant cereal with the option of tailoring down issued amount Before SPIRITAfter SPIRIT

13. C HILD 1 (1 YEAR OF AGE ) 3 gallons of whole milk 2 pounds of cheese 4 containers of juice 28 ounces cereal 2 dozen large white eggs 1 pounds beans

14. C HILD 2 (2 YEARS ) 4 gallons 2%, 1% or skim milk 2 pounds cheese 4 containers juice 28 ounces cereal 2 dozen large white eggs 1 pound beans

15. C HILD 3 (3 – 5 YEARS ) 4 ½ gallons 2%, 1% or skim milk 2 pounds cheese 6 containers juice 36 ounces cereal 2 dozen large white eggs 1 pound beans

16. C HILD /W OMAN WITH S PECIAL N EEDS Formula 36 ounces cereal 3 containers juice

17. M AJOR C HANGES TO C HILD F OOD P ACKAGE Default packages contained a standard amount and amounts could be tailored up to a maximum amount No default food package for child/woman with special needs in WANG Default packages contain maximum amounts allowed and amounts can be tailored down Default food package for child/woman with special needs Before SPIRITAfter SPIRIT

18. P REGNANT /P ARTIALLY BF W OMAN 5 ½ gallons 2%, 1% or skim milk 2 pounds cheese 6 containers juice 36 ounces cereal 2 dozen large white eggs 1 pound beans

19. E XCLUSIVELY BF W OMAN 5 ½ gallons 2%, 1% or skim milk 3 pounds cheese 7 containers juice 36 ounces cereal 2 dozen large white eggs 2 pounds beans 2 pounds carrots 26 ounces tuna

20. N ON -BF P OSTPARTUM W OMAN 4 ½ gallons 2%, 1% or skim milk 2 pounds cheese 4 containers juice 36 ounces cereal 2 dozen large white eggs

21. M AJOR C HANGES TO W OMEN ’ S F OOD P ACKAGE Term postpartum was used Default packages contained a standard amount and amounts could be tailored up to a maximum amount No default food package for child/woman with special needs in WANG Term postpartum replaced with non- breastfeeding postpartum woman Default packages contain maximum amounts allowed and amounts can be tailored down Default food package for child/woman with special needs Before SPIRITAfter SPIRIT

22. O VERALL C HANGES Whole milk could be issued to children > 2 years of age or to women if they met certain risk factor Whole milk will only be given to children 2 years of age and women will not allow whole milk to be substituted for any risk factor Before SPIRITAfter SPIRIT

23. O VERALL C HANGES Buttermilk could be issued as a regular milk alternative Buttermilk will no longer be an allowed food on the Arkansas WIC Program Before SPIRITAfter SPIRIT

24. O VERALL C HANGES Peanut butter could be issued to any child with a qualifying risk factor Peanut butter can only be issued to children > 2 years of age due to possible allergies and choking hazards Before SPIRITAfter SPIRIT Doing great! Keep up the pace!

25. O VERALL C HANGES Juice was designated on the checks as 12 ounce frozen concentrate, 11.5 ounce non-frozen pourable concentrate, or 46 ounce single strength Juice will be listed on the checks as number of containers. Ex. 3 containers of juice. Participants must select the same type of juice for each food instrument, but can vary the flavor Before SPIRITAfter SPIRIT

26. O VERALL C HANGES Could split certain items on a food package Ex. ½ package regular juice, ½ package calcium fortified orange juice Can no longer split food packages, but can alternate food items received monthly Ex. Whole package of regular juice for the month of May, and a whole package of calcium fortified orange juice for the month of June Before SPIRITAfter SPIRIT

27. F OOD P ACKAGE T AILORING

28. F OOD P ACKAGE T AILORING VS F OOD P ACKAGE C HANGES A change in the amount of a food; an addition or elimination of a food; a change that could affect the nutritional value of the food package Ex. Adding peanut butter to an underweight pregnant mom’s food package Ex. Family is eligible to receive 20 gallons of milk per month, yet normally only use 12 gallons, so the CPA tailors down the amount of milk the family receives A change in the form of an existing food type that does not affect the nutritional value of the food package Ex. Changing from regular fluid milk to powdered milk TailoringChanging

29. F OOD P ACKAGE T AILORING VS F OOD P ACKAGE C HANGES All formula changes are considered food package tailoring All special issue food items are considered food package tailoring Special issue food items include: Infant juice Concentrate or ready to use formula Calcium fortified orange juice Reduced lactose or lactose free milk Peanut butter All food package tailoring and changes are to be completed by the CPA

30. T AILORING Food packages can still be tailored based upon: Participant’s identified risks Participant’s request of decreased amounts or elimination of a food As determined nutritionally sound and beneficial by the nutritionist

31. W HAT CAN BE TAILORED Default food packages can be tailored in SPIRIT Foods tailored due to nutrition risk factors: Peanut Butter (> 2 years of age) Reduced lactose or lactose free milk

32. P EANUT B UTTER Child 103 Underweight 134 Failure to thrive 135 Inadequate weight gain 801 Homeless 802 Migrant Pregnant 101 Underweight 131 Low maternal weight gain 132 Maternal weight loss during pregnancy 331 Pregnancy at a young age 338 Pregnant woman currently breastfeeding 801 Homeless 802 Migrant Partially Breastfeeding Woman 101 Underweight 331 Pregnancy at a young age 335 Multifetal gestation 801 Homeless 802 Migrant Exclusively Breastfeeding Woman 101 Underweight 331 Pregnancy at a young age 335 Multifetal gestation 801 Homeless 802 Migrant

33. R EDUCED OR L ACTOSE F REE M ILK 355 Lactose Intolerance (child or any woman)

34. T AILORING R ULES Substitutions Child 2 and Child 3 food packages or pregnant/partially BF women may receive one 18 ounce jar of peanut butter (with appropriate nutrition risk factors) in lieu of 1 lb dry beans. Exclusively BF Women may receive one 18 ounce jar of peanut butter (with appropriate nutrition risk factors) in lieu of 1 lb dry beans. They will still receive an additional one pound of dry beans which cannot be substituted with peanut butter.

35. T AILORING R ULES Alternating With SPIRIT, food items from the same category can be alternated on the food checks Ex. Participant qualifies for peanut butter, however, they also enjoy receiving the beans. The food packages can be tailored so that one month the participant receives peanut butter and the next month they receive dry beans. It would alternate each month until the end of the certification.

36. S CENARIO 1—T AILORING OR N OT Mary B., a pregnant woman, complains of stomach discomfort, cramps, and diarrhea whenever she drinks milk. She tells the clerk she no longer wants to receive milk because it “doesn’t settle well” with her. What should happen next? a. The clerk removes the milk from the food package b. The clerk refers Mary to the CPA c. The clerk makes Mary an appointment to come back to see the CPA d. The clerk suggests getting another form of milk, helps Mary decide, and changes the food package

37. Answer B is correct! This is food package tailoring. The clerk should refer Mary to the CPA. Since Mary is considering having a food item eliminated from her food package, the CPA needs to determine if there is an alternative way to continue to supplement Mary’s diet with the nutrients she needs while providing her with an acceptable alternative.

38. S CENARIO 2—T AILORING OR N OT Henry W. is a 3 year old child who has lost weight since his last certification. He now plots at the 8 th percentile for BMI for age. Due to his risk factors, he qualifies for peanut butter. What should happen next? a. The CPA should let it go, issue the dry beans, and see how his weight looks at his next certification b. The CPA should issue peanut butter c. The CPA should ask Henry W.’s parent if they would like to receive peanut butter d. The CPA should suggest getting a prescription for PediaSure

39. Answer C is correct! This is food package tailoring and should be done by the CPA. The CPA should ask the parent or guardian if peanut butter is an acceptable substitute and if they would like to have it. If the parent says yes, then peanut butter would be issued. *Peanut butter is not commonly consumed in all cultures, thus we should always take cultural differences into consideration when tailoring a food package.

40. S CENARIO 3—F OOD T AILORING OR N OT Alli, an exclusively breastfeeding mom, comes in to pick up her checks. After receiving her first months WIC benefits, she is now requesting to receive half of her milk as dry milk and half of her milk as fluid milk. What should happen next? a. The clerk should tell her she will have to wait till her next certification appointment to make any food package changes. b. The clerk tells Alli that food package items can no longer be split, she will either have to do all fluid milk or all powdered milk. c. The clerk makes an appointment for Alli to return to the clinic to see the CPA. d. The CPA changes the food package so that Alli will receive one month of fluid milk and then one month of powdered milk.

41. The correct answer is D! This is NOT food package tailoring. The nutritional value of the package is not changing. The CPA should instruct Alli on how the milk can be divided, offer her that solution, and if agreed to, change the food package so that Alli will receive fluid milk and powdered milk alternating months.

42. Food package information has been condensed to help the CPA to determine the correct food package to issue participants. It will be available in policy. It is contained on the next 2 slides.

45. You’re halfway there!

46. F OOD P ACKAGES IN SPIRIT

47. Now that we have reviewed the default food packages available in SPIRIT, it is time to see what they will look like and how to edit if needed.

48. Once your participant has been selected and you have started the certification process you will go through several steps to determine and prescribe the right food package for the participant.

49. Using the Certification Guided Script, the CPA will be able to determine when it is appropriate to implement the food prescription.

50. When it is time to prescribe the food package, select Food Prescription.

51. The next screen will display the default food package for the patient type. Notice the date of the Rx is the date of certification.

52. Since James qualifies for peanut butter based upon his nutrition risk factors, the CPA should ask the parent or guardian if peanut butter would be an acceptable alternative to the dry beans. If the answer is yes, the CPA will then have to edit the food package. To start editing a food package, select the date of the food package you want to edit.

53. Once the correct food package date has been selected, the Edit Food Prescription screen will appear. All food items in that food package are displayed.

54. Find and select the item that needs to be edited. In this instance we will have to delete the food item dry beans before peanut butter can be added.

55. Once you have selected Delete Food Item, a box will appear asking “Do you want to delete this food item?” In this instance, we would select yes.

56. Now the food prescription screen appears without the dry beans food item listed. Now it is time to add the peanut butter. By selecting Add Food Item, we can begin this process.

57. Once you have selected to Add Food Item, a new screen will appear where you will select which food category the item you want to add belongs.

58. From the pull down menu, all food categories are listed.

59. For James, we would select Legumes (Beans/Peanut Butter.

60. When you have selected your food category, available food items will appear.

61. Now the CPA will select the peanut butter option and click OK.

62. Now the Edit Food Prescription Screen will appear and peanut butter will now be listed as part of the food prescription. Once all changes have been made, clicking OK will allow the CPA to exit this screen

63. The CPA will now be returned to the Food Prescription screen. Note the food prescription now contains the changes made by the CPA.

64. When the CPA closes the Food Prescription window, the Certification Guided Script will appear and the Food Prescription task will be checked as completed.

65. Let’s look at another participant…….

66. Our next participant is Eva. As you can see from the screen she is a pregnant woman.

67. Eva is now at the point in her certification where her food package needs to be prescribed by the CPA. Based upon her risk factors, Eva not only qualifies for peanut butter, but she is lactose intolerant.

68. After selecting Food Prescription, this is the next screen that will be shown. The default food package for a pregnant woman is displayed, along with the date the food prescription was given.

69. Since Eva qualifies for peanut butter and lactose free milk, these options should be discussed and offered to her by the CPA. In this case, Eva would like to receive both of those substitutions. So, the date of the food prescription will be selected so that the food package can be edited. Almost done!

70. The first item this CPA has chosen to change is the dry beans. The dry beans are chosen as the food item to delete.

71. The dialog box will pop up to confirm the food item should be deleted. For Eva, “yes” would be selected.

72. Once an item has been deleted, the CPA will be returned to the Edit Food Prescription screen. From here, the CPA should choose to Add Food Item so that peanut butter can replace the dry beans.

73. Once the Add Food Item button is clicked, the Add Food Item dialog box will appear. From this screen, the food category of the item should be selected.

74. The drop down box will display all possible food categories.

75. The CPA should select Legumes (Beans/Peanut Butter). By selecting this food category item, the possible food items will be listed.

76. For Eva, the CPA would select 18 oz jar(s) Peanut Butter and click OK.

77. The Food Prescription now displays the peanut butter. It is now time for the CPA to tailor the rest of the food package.

78. Since Eva is lactose intolerant and has accepted the lactose free milk option, the CPA will now have to remove the milk listed in the default food package. The first step would be to delete the gallons of regular milk listed in the food prescription.

79. Same as with the peanut butter, the CPA will be asked if this food item should be deleted. The CPA will again select “yes”.

80. The Edit Food Prescription now no longer displays the gallons of milk. However, the CPA must remember to remove the half gallon of milk as well.

81. The CPA would follow the same steps as before to delete the half gallon of milk from the food prescription.

82. The CPA would be prompted to select “yes” on deleting the food item.

83. The food prescription is now void of all fluid milk. Now it is time to add the lactose free milk to the food prescription.

84. The CPA would again choose Add Food Item.

85. The Food Category drop down list would again be accessed.

86. This time the CPA would select the food category of milk and click OK.

87. From the list of the food items, the CPA would scroll until they found the appropriate item. In this case, it would be half gallon(s) Lactaid or Dairy Ease (2%, 1% or Fat Free). * Note: Lactaid and Dairy Ease are not available in gallon size containers.

88. The new prescribed food package now appears on the Edit Food Prescription screen. The CPA has completed all necessary changes and may now click OK.

89. The tailored food prescription now appears on the Food Prescription screen.

90. Now that the CPA has completed the Food Prescription section of the certification, it will be checked off the Certification Guided Script.

91. This is only a slight introduction to food prescriptions in SPIRIT. The main focus of this module should be the changes to our current food packages. By making some modifications to the food packages now, we will be positively positioned when we implement the new WIC Food Packages in 2009.

92. The End! You have just completed the SPIRIT Food Package Training! Good job!